The Ethical Practice of Psychotherapy: Easily WithinOur ReachmJeffrey E. BarnettIndependent Practice, Arnold, Maryland and Loyola Collegein MarylandPsychotherapists confront a myriad of ethical dilemmas as theyendeavor to provide effective services. This issue of theJournal ofClinical Psychology: In Sessionon Ethics in Psychotherapy providespsychotherapists with thoughtful reviews, case examples, andpractical guidance in the major areas of ethics. Following this briefintroduction, the subsequent seven articles cover Informed consent;confidentiality, privilege, and their limits; treatment of minors and theirfamilies; business matters of practice (e.g., money, fees, bartering,advertising); clinical competence and scope of practice; boundariesand nonsexual multiple relationships; and termination and abandon-ment. This issue is designed to promote ethical practice, to provideguidance on common ethical dilemmas, and to prevent ethicalchallenges before they occur.&2008 Wiley Periodicals, Inc. J ClinPsychol:In Session 64: 569–575, 2008.Keywords: ethics; psychotherapy; ethical practice; dilemmas; profes-sional conductThe practice of psychotherapy can be highly rewarding, yet quite challenging. Despitetheir extensive training and best efforts, psychotherapists often find themselves ill-prepared for the wide range of ethics dilemmas that face them. This issue of theJournal of Clinical Psychology: In Sessionbrings together distinguished experts inmental health ethics to educate and guide practitioners in successfully navigating someof the most common and challenging ethical dilemmas in psychotherapy. Respectedauthors address seven of these challenges: Informed consent; confidentiality, privilege,and their limits; treatment of minors and their families; business matters of practice(e.g., money, fees, bartering, advertising); clinical competence and scope of practice;boundaries and nonsexual multiple relationships; and termination and abandonment.Correspondence concerning this article should be addressed to: Jeffrey E. Barnett 1511 Ritchie Highway,Suite 201, Arnold, MD 21012; e-mail: drjbarnett1@comcast.netJOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 64(5), 569–575 (2008)&2008 Wiley Periodicals, Inc.Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20473The overarching aim of the issue is to assist psychotherapists in rendering the mostethical and effective services possible.In this brief introduction, I offer a practical approach to ethical practice thataddresses the complexities of psychotherapy practice, the many forces that createethics challenges, and that can be integrated easily into each psychotherapist’s dailypractices. Then I introduce the following articles in this issue and the essentialaspects of ethical practice each addresses.The Ethical Practice of PsychotherapyPsychotherapists can adopt several strategies in their efforts to practice ethically.These include positive or aspirational ethics, risk management, and defensivepractice (Barnett, 2007).Positive ethicsfocuses the psychotherapist on constantlystriving to achieve the highest ethical standards of our profession. It is guided by aseries of aspirational virtues that we strive to achieve throughout our careers. Thesevirtues provide both important direction and a conceptual framework. These virtuesinclude:*beneficence: doing good and providing maximum benefit to those psychothera-pists serve*nonmaleficence: avoiding exploitation and harm of clients and those associatedwith them*fidelity: being faithful to the explicit and implicit obligations psychotherapistshave to their clients*autonomy: promoting each client’s independence of us over time and not creatingincreased dependence on us through our actions*justice: providing fair and equal treatment, and access to treatment, to allindividuals*self-care: providing adequate attention to our own physical and psychologicalwellness so that we are effectively able to implement the preceding virtues(Beauchamp & Childress, 2001).These virtues can generate a series of questions that may be of assistancewhen facing dilemmas. For example, ‘‘Will taking this action be in my client’sbest interest?’’ ‘‘Will engaging in this behavior increase the likelihood of exploitationor harm of my client?’’ ‘‘Is acting in this way consistent with my obligations to myclient and consistent with my client’s expectations of me?’’ ‘‘Will proceeding with thiscourse of action promote greater dependence on me by my client?’’ ‘‘Am I singlingout this particular client for unique or special treatment in some way?’’ ‘‘Are therepersonal factors that I have overlooked that may be contributing to my decision toengage in this planned course of action?’’Positive or aspirational ethics strive to achieve the highest ideals of ethical andprofessional conduct in all our interactions with clients (Knapp & VandeCreek,2006). It eschews efforts to do the minimum to get by or to just avoid negativeoutcomes. Further, positive ethics focuses on the best possible outcome for the client.Risk managementshares the goal of positive outcomes for clients, but it is morespecifically focused on minimizing risks for the psychotherapist that may result inethics complaints or malpractice claims. Risk management attends to data on themost likely causes of complaints against psychotherapists and utilizes them todevelop practice models to reduce the probability of these pitfalls. Effective riskmanagement most frequently addresses informed consent, effective documentation,570Journal of Clinical Psychology: In Session, May 2008Journal of Clinical Psychology: In SessionDOI: 10.1002/jclpand consultation (Bennett et al., 2006). While reducing the risk of an ethicscomplaint or malpractice claim is obviously of great importance to all psychothera-pists, as will be seen in the following articles, effective ethical practice embraces riskmanagement, but retains its focus on the client’s best interests rather than onprotecting the psychotherapist.Defensive practicefocuses on the direct protection of the psychotherapist. Itinvolves making decisions based on reducing the possibility of adverse outcomes forthe psychotherapist (Barnett, 2007). For example, a practitioner may restrict therange of clients worked with and refuse to work with certain types of clients, such asthose with suicidal ideation or severe personality disorders, out of fear that theymaterially increase risk (Wilbert & Fulero, 1988). As highlighted in the articles tofollow, overzealous efforts to avoid all possible risk can actually result in greaterharm to clients. For example, an absolute refusal to cross certain boundaries inpsychotherapy, such as self-disclosure and touch, can result in poorer treatmentoutcomes and may not be in the client’s best interests (Williams, 1997; Zur, 2001).The authors of articles in this issue consistently emphasize positive ethics.Focusing on the client’s best interests and aspiring to the highest ideals of ourprofession are most likely to achieve the best treatment outcomes, to assistpsychotherapists in effectively responding to the inevitable ethics challenges weconfront, and incidentally, to minimize risks to the psychotherapist.The Regulatory EnvironmentThe regulation of healthcare practice creates it own set of complications to positiveethics. The regulatory environment refers to one’s practice setting and the manystandards, regulations, laws, and policies that regulate the practice of psychotherapy.All psychotherapists must follow the ethics code of their profession, such as theEthical Principles of Psychologists and Code of Conduct(Psychological Association,2002; hereinafter referred to as the ‘‘Ethics Code’’), and state laws and regulationsrelevant to their status as a licensed professional. Additionally, depending on one’spractice setting, other policies and regulations must be considered. Psychotherapistsworking in institutions such as state hospitals, federal prisons, county schools, andthe like will find a plethora of documents that regulate how they conduct themselvesin their professional roles.Psychotherapists also must be aware of prevailing professional standards in certainareas. Knowledge of the professional literature in one’s area of practice is an ethicalduty for keeping aware of changes in practice patterns and recent developments thatmay alter accepted practices. Psychologists, for example, should familiarizethemselves with American Psychological Association’s (APA) various practiceguidelines that reflect the current consensus of experts in a number of specificpractice areas such as the treatment of older adults, girls and women, and ethnicallydiverse populations. These may be accessed at www.apa.org/practice/prof.html.Ethical Decision MakingWhen faced with ethical dilemmas, psychotherapists will seek information from thelaw, professional publications, and colleagues to guide them in their decisionmaking. Consider the following two illustrative examples:A psychotherapist receives a telephone call from an individual identifyingherself as the noncustodial parent of one of the psychotherapist’s clients.571Ethical Practice of PsychotherapyJournal of Clinical Psychology: In SessionDOI: 10.1002/jclpThe client is a minor, and the psychotherapist correctly had the custodialparent consent to the child’s psychotherapy. But the psychotherapist isunsure of how to respond to this request since the noncustodial parent hasnot been involved in the treatment and the custodial parent does not wanther involved.The first thing the psychotherapist did was review the Ethics Code and its sectionson informed consent to psychotherapy. While the psychotherapist did follow thesestandards, the issue of the noncustodial parent’s access to treatment information hadnot been addressed. The psychotherapist next sought consultation with a colleaguewith expertise in ethics and legal issues in psychotherapy. The colleague referred thepsychotherapist to a particular section of law in their state that authorizes allnoncustodial parents to have access to all treatment information concerning theirchildren. While they cannot consent to their children’s treatment, they do have thelegal right to all information about the treatment and to participate in it if desired.Then, after reading several articles in the professional literature, the psychothera-pist learned more about preventive practices with regard to the treatment of minorsand the involvement of their parents in treatment. Based on recommendations in theliterature, the psychotherapist scheduled a meeting with both parents, reviewedrelevant Ethics Code standards and the relevant statute, and then together theymodified the original informed consent agreement to the satisfaction of all involved.The minor client’s psychotherapy then proceeded successfully.A male psychotherapist is providing treatment to an attractive female client.Over the course of treatment, the psychotherapist realizes he is becomingattracted to the client. He understands his obligation to focus on his client’sbest interests, but is unsure of how to deal with his feelings and how toproceed.The psychotherapist reviews relevant sections of the Ethics Code, includingstandards on multiple relationships, avoiding exploitation and harm, and attentionto one’s personal functioning and how it may impact client welfare. He then readsrelevant professional literature on personal feelings toward clients, boundary issuesand multiple relationships, self-care, the use of consultation and personalpsychotherapy, and when to restrict or limit one’s scope of practice.The psychotherapist then consulted with an experienced, trusted colleague anddiscussed the situation openly and honestly. As a result of this consultation andupon self-reflection, the therapist realized that he has been under stress in hispersonal life lately and that this may be impacting his professional conduct. With thesupport of his colleague, he seeks personal psychotherapy and begins to addressthese concerns with his psychotherapist. With what he learns and now understandsbetter, he is able to continue his clinical work with this client and do so in an ethicaland appropriate manner.As can be seen in these case examples, a primary source of guidance when facedwith ethics dilemmas is the ethics code of one’s profession. The Ethics Code providesboth general principles that are aspirational in nature (based on and applied like thevirtues) and a code of conduct comprised of enforceable minimal expectations forprofessional conduct. Each is important for considering how to provide psychother-apy in the most ethical manner possible. But, the Ethics Code makes it clear that itcannot specifically address every situation or dilemma that a psychotherapist mayface. Further, it states that psychotherapists are to consider the Ethics Code in their572Journal of Clinical Psychology: In Session, May 2008Journal of Clinical Psychology: In SessionDOI: 10.1002/jclpethics decision making, but also should consider relevant laws and regulations aswell as ‘‘.yother materials and guidelines that have been adopted or endorsed byscientific and professional psychological organizations and the dictates of their ownconscience, as well as consult with others in the field’’ (p. 1062).As one of several sources of guidance, the Ethics Code does not replace thepsychotherapist’s judgment but should be used in concert with it. A number ofmodels of ethical decision making are available that can guide the psychotherapistwhen faced by challenges with no readily clear course of appropriate action. Clauseand Cottone (2000) provided an excellent review of available decision-makingmodels. Further, psychotherapists may access the Markkula Center for AppliedEthics’ Web site at http://www.scu.edu/ethics/practicing/decision/ for a helpful set ofethical decision-making resources.Challenges for Ethical PracticeAPA’s Ethics Committee (2004, 2005, 2006) regularly compiles the types andfrequency of complaints received against psychologists. In the recent past, the mostcommon complaints, in order of decreasing frequency, entail*boundary problems and multiple relationships, both sexual and nonsexual*practicing outside one’s areas of competence*insurance and fee issues*confidentiality*false, fraudulent, or misleading public statements*child custody evaluations*inappropriate follow-up and termination*inappropriate response to a crisis.These categories are not necessarily mutually exclusive. For example, whenconducting a child custody evaluation, a clinician may practice outside of areas ofcompetence while engaging in an inappropriate multiple relationship. Othercombinations of unethical behaviors among these categories may easily be seen.Regardless, these most challenging areas of clinical practice closely mirror thearticles in this issue. The seven ensuing articles offer thoughtful reviews, caseexamples, and practical guidance on the ethics of psychotherapy.Overview of ArticlesIn the first article, ‘‘Informed Consent to Psychotherapy: Protecting the Dignity andRespecting the Autonomy of Patients,’’ Celia Fisher and Matthew Oransky addressthe critical role of informed consent in the psychotherapy process. They emphasizethe role of a thoughtful and comprehensive informed consent process as a means ofpromoting clients’ best interests and in laying a foundation for the psychotherapyrelationship. Informed consent minimizes risks to clients and prevents manypotential ethics challenges. Their numerous case examples and practical suggestionswill help psychotherapists to develop informed consent procedures that should helpavert many of these challenges.Jeffrey Younggren and Eric Harris then address confidentiality and privilege,along with their exceptions in their article, ‘‘Can You Keep a Secret? Confidentialityin Psychotherapy.’’ These authors explain the centrality of confidentiality for thesuccess of every psychotherapy relationship, explain how it differs from the legalconcept of privilege, and highlight the multiple threats to confidentiality that exist.573Ethical Practice of PsychotherapyJournal of Clinical Psychology: In SessionDOI: 10.1002/jclpFurther, they utilize case law and provide practice recommendation so that eachclient’s confidentiality may be optimally preserved.Gerald Koocher, in his article entitled ‘‘Ethical Challenges in Mental HealthServices to Children and Families,’’ expands on consent and confidentiality as theyspecifically apply to clinical work with minors and their families. Koocher applies the4-C model—competence, consent, confidentiality, and congruence of interests—when children and their parents participate in or set goals for psychotherapy. Hisarticle addresses the unique challenges that confront psychotherapists who mustbalance competing interests of children and their parents. Koocher providesthoughtful analyses of these most frequent dilemmas and offers practicalrecommendations to help prevent ethical lapses.Samuel Knapp and Leon VandeCreek then address the ‘‘business’’ of psychother-apy in their article, ‘‘The Ethics of Advertising, Billing, and Finances inPsychotherapy.’’ They tackle the sticky topics of advertising, billing, and finances,which may adversely impact the psychotherapy process and relationship if notproperly addressed. They do so through realistic case examples and by applyingvirtues to assist psychotherapists in achieving the highest ideals in business practices.In her article, ‘‘Competence and Scope of Practice: Ethics and ProfessionalDevelopment,’’ Erica Wise addresses the complexities and challenges of establishingclinical competence. Through case examples, she emphasizes a comprehensive andproactive approach to competence that utilizes self-reflection and self-care alongwith ongoing professional development.Next, Kenneth Pope and Patricia Keith-Spiegel provide a thoughtful approachfor managing boundary concerns and nonsexual multiple relationships inpsychotherapy in their article, ‘‘A Practical Approach to Boundaries inPsychotherapy: Making Decisions, Bypassing Blunders, and Mending Fences.’’Their realism is sensitive to clients’ treatment needs, individual differences, and thepotential of negative client reactions. Importantly, they provide psychotherapistswith a detailed review of frequently occurring cognitive errors that may lead toharmful results.In the final article, ‘‘Psychotherapy Termination: Clinical and Ethical Responsi-bilities,’’ Melba Vasquez, Rosie Bingham, and Jeffrey Barnett address the final phaseof psychotherapy: termination. They highlight differences between termination andabandonment, discuss the many ways that a psychotherapy relationship may end(both planned and unplanned), and recommend practical steps to help ensure asuccessful outcome to the psychotherapy process.In the end, our hope is that this compilation will provide psychotherapists with asolid foundation for ethical practice. These articles provide practical strategies foraddressing the most common ethical challenges. Learning how to prevent thesechallenges when possible, and how to respond to them thoughtfully and effectivelywhen they arise, will serve the best interests of all psychotherapists, and even moreimportantly, the best interests of our clients.ReferencesAmerican Psychological Association. (2002). Ethical principles of psychologists and code ofconduct. American Psychologist, 57, 1060–1073.American Psychological Association, Ethics Committee. (2004). Report of the EthicsCommittee, 2003. American Psychologist, 59, 434–441.574Journal of Clinical Psychology: In Session, May 2008Journal of Clinical Psychology: In SessionDOI: 10.1002/jclp********************************************************************************************************************* Ethics in Psychotherapy Analysis Worksheet Use this worksheet and your understanding of critical thinking and the structure of an argument to analyze the article on ethics in psychotherapy from u03s3. To fill out the worksheet, work your way down through the analysis components and include your responses in the box next to the component. There are notes in the margins to help you flesh out the line of reasoning of the author, so use the notes along with your own interpretations as you fill out the analysis worksheet. You will submit this worksheet to the Unit 3 assignment area. Name: [Delete this message and insert your name] Analysis Components Ethics in Psychotherapy Article Barnett, J.E. (2008) The ethical practice of psychotherapy: easily within our reach. Journal of Clinical Psychology, 64(5), 569-575. The main purpose of this article is…[State as accurately as possible the author’s purpose (goal, intention, desired outcome) for writing this article] The problem to be solved is…[Identify the problem or issue the author is addressing in this article] The point of view of the author is…[Identify the author’s position or point of view in this article; who or what group does he represent?] The information the author provides to support his position is… [How do we know there is a problem?  What evidence is there that this problem exists?] The main conclusion[s] in this article are…[Identify the key conclusions or solutions to the problem the author provides in this article] If we accept the author’s line of reasoning, the implications are…[What possible or probable consequences does the author’s argument imply for the practice of psychotherapy?]